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Guidelines for Successful DME Medical Billing

DME medical billing

What is DME Medical Billing?

DME medical billing includes billing done for artificial limbs and crutches, hospital beds, neck braces, prosthetics, walkers, wheelchairs, ventilators, nebulizers, kidney machines, and other medical supplies. DME medical billing is a complex and evolving field of medical billing. It requires an in-depth understanding of the HCPCS Level II codes and the DME reimbursement process.

DME Billing Guidelines

DME or durable medical equipment is any equipment recommended for a patient to help them overcome a medical condition or illness. The DME helps the patient with their daily life at home or in a non-hospital setting. Here are the DME medical billing guidelines.

  • A DME is to be used repeatedly over three years and serves a clear medical purpose. The DME billing should not be for consumable or disposable unless it is essential for the effective use of the DME.
  • It can only be done for equipment considered medically necessary.
  • The patient must be given a prescription.
  • The medical practice must obtain prior authorization from the payer for DME billing.
  • DME coverage benefits are typically for a DME with minimum specifications to meet the patient’s requirements. For instance, the coverage is for a standard power wheelchair versus a customized wheelchair. When the patient chooses to rent or buy a DME that exceeds the payor guidelines, the patient is responsible for meeting the additional cost of the DME.
  • Also, DME medical billing typically cannot be done for accessories added for the patient’s comfort or convenience, such as air purifiers or humidifiers.
  • Medicare will pay claims only for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service.
  • As a condition for payment, a physician, Physician Assistant (PA), Nurse Practitioner (NP), or Certified Nurse Specialist (CNS) must document a face-to-face encounter examination with the beneficiary six months before the written order for the specific items of DME.

Steps involved in DME Claims Submission

Here are the steps involved:

  • A provider identifies DME requirements to provide specialized care for a patient.
  • The provider documents the medical necessity with thorough documentation.
  • The provider’s medical billing company obtains prior authorization to procure DME supplies.
  • It is always a good practice to have an advanced beneficiary notice or ABN in place so that in the event the equipment doesn’t get paid, the patient is responsible for the amount.
  • After the prior-authorization approval, the DME is collected by the patient from the DME supplier.
  • The medical billing company assigns the appropriate HCPCS Level II codes and submits the DME claim to the payor.
  • The accounts receivables management team follows up on the claim to ensure accurate payment posting.

DME billing allows for rentals and requires that you capture the correct HCPCS codes (Healthcare Common Procedure Coding System).

Read the CGS DME certification guidelines.

Overcoming the Challenges of DME Billing

The challenge with medical billing is that the guidelines vary across payors and product lines, and DME claim denials tend to be higher than any category of medical claims. Staying up to date with the latest DME medical billing guidelines is essential to your practice receiving payments on time. Given the complexity, most providers prefer to outsource the function to a specialist billing company that can ensure the correct use of HCPCS codes and claims submission as per the latest payor guidelines.

Note: If your practice has DME medical billing, you may receive a Medicare DME Claims audit request. Ensure you respond to the audit request by the deadline and submit the requested claim documents.

We hope the above information answers many of your questions on DME medical billing. Don’t hesitate to get in touch with us for further queries. Subscribe to our blog for continued updates on healthcare revenue cycle management. Follow us on Facebook, LinkedIn, Twitter, and Instagram.

 

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